Prescription heroin to hit Vancouver streets in a first for North America

Starting the week of November 23, doctors will administer prescription heroin to a select group of patients in Vancouver.

It will be the first time that heroin, or diacetylmorphine, is given to patients anywhere in North America outside of an academic study. (Update: The date on which doctors began providing patients with prescription heroin was Wednesday, November 26.)

“For this group, the addiction is so severe that no other treatment has been effective,” said David Byres, vice president of acute clinical programs at Providence Health Care. “The goal is stabilization.”

The harm-reduction program will be run out of Providence Crosstown Clinic in the Downtown Eastside. In a telephone interview, Byres emphasized that heroin-assisted treatment is only recommended as an appropriate intervention for individuals who have repeatedly failed with traditional therapies such as methadone.

In accordance with a B.C. Supreme Court injunction granted in May 2014, to be eligible a patient must have participated in the Study to Assess Longer-term Opioid Medication Effectiveness (SALOME), an academic program that began at Crosstown Clinic in 2011. Byres noted that the average SALOME participant has failed with traditional treatment for opioid dependence an average of 11 times.

That group consists of 202 people. Of that group, Byres said, doctors have written diacetylmorphine prescriptions for 120 participants. However, only 26 will begin receiving treatment next week because so far diacetylmorphine shipments from Europe via Ottawa have only arrived for that many.

Byres explained that for each patient, a physician must not only write a prescription but must also submit an application to the federal Special Access Program (SAP). Only after an application is approved in Ottawa will Crosstown Clinic receive a patient’s diacetylmorphine.

In a separate interview, Dr. Scott MacDonald, physician lead at Crosstown Clinic, said it is his experience that patients are not taking diacetylmorphine to get high but merely to function normally.

“It is a difficult therapy to take,” MacDonald said. “People need to come to this clinic three times a day in order to get their medication.”

Patients will only receive a dose of diacetylmorphine if they visit the clinic at set times in the morning, afternoon, and evening, MacDonald continued. There are eight groups of patients and, therefore, eight different times for each dose. Each group has only a 10-minute window to enter the clinic.

Inside the clinic, the procedure remains highly controlled. Describing a process originally designed for SALOME, MacDonald said staff confirm a patient’s identity and then assign them to a nurse who performs an initial assessment. If an individual is deemed well enough, they proceed to the injection room and receive their dose of diacetylmorphine as well as a syringe and other equipment required for intravenous drug use. They have 10 minutes to administer the drug. Finally, there is a waiting area where patients remain under observation for a short time before they are permitted to leave the clinic. The entire process takes 30 minutes or less.

MacDonald emphasized the clinical nature of the program. He noted that patients walk out of Crosstown Clinic shortly after injecting diacetylmorphine, unlike depictions of heroin use in movies where users nod off.

“This is safe, evidence-based treatment,” he said. “When people first come off the street, they are often unstable. But within a few weeks here [SALOME]—and sometimes it’s just days—we see a remarkable turnaround.”

According to Byres, the average cost of one patient’s treatment is $27,000 per year, an expense that is covered by Providence (and therefore taxpayers). He noted that includes administration costs and said it’s a small part of that figure that goes to paying for the drug itself.

Byres quickly pointed to a 2004 study published in the Royal Institute of Public Health about heroin use in Canada. “The overall social cost of one untreated opioid-dependent person in Toronto has been estimated to be $45,000/year.”

Byres also called attention to academic studies such as the North American Opiate Medication Initiative (NAOMI), conducted in Vancouver and Montreal, that suggests heroin-assisted treatment programs have added benefits that stem from patients interacting with a nurse or doctor instead of a dealer.

“When they come into the clinic, not only do they receive treatment for their addiction; they receive primary care or medical treatment, they can get counselling, they can get mental-health care,” Byres said.

He added that many of the same studies have shown participants given diacetylmorphine also record reduced criminal involvement.

“Diacetylmorphine has proven effective in multiple trials around the world,” he said. “Over time, as patients stabilize, other health outcomes improve, they have less illegal or illicit activities.”

The Conservative government has strongly opposed doctors prescribing diacetylmorphine in Vancouver. Health Canada did not make a representative available for an interview by deadline.

Interviewed by the Straight in March 2014, Health Minister Rona Ambrose maintained her office’s positon is grounded in science.

“There are scientists and researchers, clinicians, who have worked in the area of addictions for decades, who believe that this is a good decision,” she said. “I’m happy to provide you with some their accounts.”

In the months that followed, Health Canada did not respond to repeated requests for those records. Finally, in October 2014, a freedom of information request revealed the ministry consulted only one scientific report on the matter; furthermore, the evidence presented in that document contradicts opinions on diacetylmorphine voiced by Ambrose.

In October 2013, B.C. Health Minister Terry Lake expressed his support for heroin-assisted treatment.

“We have to think outside of the box sometimes,” he said. “I know that the thought of using heroin as a treatment is scary, but I think we have to take the emotion out of it and let science inform the discussion.”

Rick in PoMo

So, addicts are going to have access to prescription heroin, but the terminally ill in hospitals in Canada are not offered anything stronger than morphine for pain relief, to my knowledge.

In the UK, thirty years ago my father had prostate cancer that had metastasised to the bones and needed strong pain relief. When morphine was not enough, he was prescribed heroin. My mother, a retired nurse, was taking care of him at home. Health visitors would come to the house every four hours around the clock to administer the heroin dose. At a holiday weekend, we ran out of heroin and could not get any more from the pharmacy and my father had to go into hospital to receive it. The nurses were amazed how much heroin he needed to control the pain and remarked that if someone not used to heroin had taken that amount, it would have killed them.

So, back to my original point. When will heroin be available as a painkiller of last resort to terminally ill patients in Canada?

Martin Dunphy

DB

Nov 24, 2014 at 10:27pm

Rick in PoMo: some patients are offered fentanyl and even sufenta, which is many, many times stronger than morphine. There are many other medications stronger than morphine administered in the hospital. The pharmaceuticals have changed a lot in the past 30 years and heroin isn't an ideal painkiller, especially when there are other, more effective options.

Sara

Dec 2, 2014 at 7:51am

Rick in Pomo:Heroin really isn't an ideal painkiller, and something like fentanyl, dilaudid, or oxymorphone (all of which are given to chronic pain patients, terminally ill individuals, etc) are a bit more ideal.

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